Basic Information
| Provider Information | |||||||||
| NPI: | 1225708167 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEYS | ||||||||
| FirstName: | VICKIE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CERTIFIED PRSS | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 690184 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741690184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5393671677 | ||||||||
| FaxNumber: | 5393671991 | ||||||||
| Practice Location | |||||||||
| Address1: | 2508 E 71ST ST STE C | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741365572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187946570 | ||||||||
| FaxNumber: | 9183405189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2021 | ||||||||
| LastUpdateDate: | 02/15/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | OK | Y |
ID Information
| ID | Type | State | Issuer | Description | 1225708167 | 05 | OK | MEDICAID |